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Report on the health of refugees and migrants in the WHO European Region

This report, the first of its kind, creates an evidence base with the aim of catalysing progress towards developing and promoting migrant-sensitive health systems in the 53 Member States of the WHO European Region and beyond. This report seeks to illuminate the causes, consequences and responses to the health needs and challenges faced by refugees and migrants in the Region, while also providing a snapshot of the progress being made across the Region. Additionally, the report seeks to identify gaps that require further action through collaboration, to improve the collection and availability of high-quality data and to stimulate policy initiatives.

The 53 countries of the WHO European Region have a population of almost 920 million, representing nearly a seventh of the world’s population; international migrants make up almost 10% (90.7 million) in the Region and account for 35% of the global international migrant population (258 million). The proportion of international migrants, including refugees, in Member States of the Region varies from more than 50% in Andorra and Monaco to less than 2% in Albania, Bosnia and Herzegovina, Poland and Romania. As a consequence, displacement and migration-related programme and policy priorities may vary between Member States. Yet, every country today can be an origin, transit or a destination country for refugees and migrants, sometimes acting as more than one of these. As a result, the health of refugees and migrants has progressively emerged as a theme of common interest for all Member States. At present, there are no global or region-wide indicators or standards for refugee and migrant health, and no global or regional framework is currently implemented for the standardized and routine collection of data. This leads to a shortage of scientifically valid and comparable health data on refugee and migrant populations.

Across the WHO European Region, there are fundamental differences in the way health services are organized, financed and governed for the population as a whole, with health policies for refugees and migrants adding a further layer of complexity. Differences exist between countries in access requirements to health services and the level of implementation of regionally agreed strategies, recommendations and policies, particularly for migrants in an irregular situation (irregular migrants). In general, regional health policies recommend or define that emergency and urgent care should be available to all refugees and migrants throughout the Region, regardless of legal status.

Improving health for all and reducing health inequalities are key parts of many WHO strategies, action plans and frameworks, both globally and regionally. This report is intended to create an evidence base to aid Member States of the WHO European Region and other national and international stakeholders in promoting refugee and migrant health by implementing the Strategy and Action Plan for Refugee and Migrant Health in the WHO European Region, which incorporates the priority areas listed in  Health 2020, the WHO European Region’s policy framework for the promotion of equitable health and well-being.

Refugee and migrant health is a highly complex topic and research findings often cannot be generalized to wider refugee and migrant populations in a country, in a region or globally. The effects of the migratory process, social determinants of health and the risks and exposures in the origin, transit and destination environments interact with biological and social factors to create different health outcomes.

Mortality estimates tend to be lower in refugees and migrants than in the European host population for allcause mortality, neoplasms, mental and behavioural conditions, injuries, endocrine conditions and digestive conditions. Summary standardized mortality ratios are estimated to be higher for infections, external causes, diseases of the blood and blood-forming organs and cardiovascular diseases. Refugees and migrants can be vulnerable to infectious diseases because of lack of health care or interrupted care in the country of origin, because of exposure to infections and lack of care in transit, and if living conditions are poor in the destination country.

There are indications that there is a very low risk of transmitting communicable diseases from the refugee and migrant population to the host population in the WHO European Region. It is possible that refugees and migrants arriving from countries with a high prevalence of tuberculosis (TB) might reflect a similar prevalence. However, the proportion of refugees and migrants among a country’s TB cases varies from more than 90% to less than 1%, reflecting the prevalence in the host country. The same is true for HIV. A significant proportion of those refugees and migrants who are HIV positive acquire infection after they have arrived in the Region, and they are more likely to be diagnosed later in their HIV infections. Infections with hepatitis B virus (HBV) and hepatitis C virus (HCV) are more common among refugees and migrants arriving from countries with high endemic disease, but prevalence of these infections among refugee and migrant populations varies across the Member States of the Region. Tropical and parasitic infections that are not normally seen in Europe may enter the Region via refugees, migrants and travellers originating from or visiting areas of higher endemicity.

Research indicates that the duration of stay in the host country within the WHO European Region can be positively associated with an increase in risk for a noncommunicable disease (NCD) such as cardiovascular diseases, stroke or cancer. Although, generally, there is a higher risk of ischaemic heart disease and stroke among the refugee and migrant population, there is no clear pattern for cardiovascular diseases and prevalence may be linked as much to socioeconomic factors as to migration-specific factors. Refugees and migrants have a lower risk for all neoplasms except cervical cancer, for which they are also more likely to be diagnosed at a later stage in their disease than the host populations in the Region. In general, refugees and migrants in the Region have a higher incidence, prevalence and mortality rate for diabetes than the host population, with higher rates seen in women than men depending on the country of origin.

Prevalence of mental disorders in refugees and migrants shows considerable variation depending on the population studied and the methodology of assessment. Risk factors for mental health problems may be experienced during all phases of the migratory process and in settling in the host country. Post-traumatic stress disorder (PTSD), mood disorder and depression are the most frequently reported conditions among international migrants, mainly for refugees and recently arrived asylum seekers. However, the evidence is not conclusive and there is a wide range in the reported prevalences. For example, the reported prevalence of depression in the refugee and migrant population varied from 5% to 44%, compared with a prevalence of 8–12% in the general population. Poor socioeconomic conditions, such as unemployment or isolation, are associated with increased rates of depression in refugees after resettlement. Migration was also found to be a risk factor for children’s mental condition, and unaccompanied minors experience higher rates of depression and symptoms of PTSD compared with other refugee and migrant groups.

Labour migrants constitute the largest group of migrants globally. Around 12% of all workers in the Region were migrants in 2015. Conditions of employment vary drastically as do the health hazards of the jobs and the access to social and health protection. Male migrants experience significantly more  work-related injuries than non-migrant workers, whereas rates for female migrants appear to be similar to those of the host population.

For female refugees and migrants, there is a marked trend for worse pregnancy-related indicators. However, refugee and migrant women can be protected from adverse obstetric and perinatal health outcomes through personal factors such as socioeconomic and educational status and characteristics of the host country (e.g. having a strong integration policy). Knowledge of family planning is varied among refugees and migrants, and in general they may also lack awareness of available health support. Sexual violence can occur for refugees and migrants in transit settings and in countries of destination, creating increased vulnerability to sexually transmitted infection (STI). Refugee and migrant children may be more prone to health issues related to diet, both malnutrition and overweight/obesity. As noted above, migration is also a risk factor for mental disorders in children. Utilization of primary care services by refugees and all categories of migrant is affected by the organization of the health system and whether payments are required for access. Preventive care includes both measures that prevent ill health (e.g. immunization and health education) and those that detect ill health at an early stage so that treatment can be introduced when it works best (e.g. screening and health checks). Provision of ethical and effective screening and health care for migrants at borders is an important step towards ensuring the health needs of refugees and migrants moving on into host communities.

Reflecting World Health Assembly resolution WHA 61.17 in 2008 and the subsequent global consultation in Madrid in 2010, the WHO Regional Office for Europe engaged with Member States, partner organizations and other stakeholders in advancing and implementing identified refugee and migrant health strategies and priorities. Important aspects of this work included both support to integrate the health needs of refugees and migrants into national health strategies, policies and programmes of Member States and assistance in scaling up preparedness and response in relation to the complex crisis and mixed flows of refugees and migrants from the Middle East and north Africa that emerged in 2011. Critical to these activities was adoption of Health 2020 by the 62nd session of the WHO Regional Committee for Europe in 2012 and other major regional policy frameworks aimed at facilitating and supporting universal, sustainable, high-quality, inclusive and equitable health systems. Health 2020 drew particular attention to displacement, migration and health, as well as issues of population vulnerability and human rights, and has provided a comprehensive foundation for public health work in the Region. Furthering the work done within this area, a High-level Meeting on Refugee and Migrant Health in the WHO European Region was held in Rome in 2015, where Member States agreed on the need for “a common framework for collaborative action on refugee and migrant health, acting in a spirit of solidarity and mutual assistance, to promote a common response, thereby avoiding uncoordinated single-country solutions”. The Strategy and Action Plan for Refugee and Migrant Health in the WHO European Region was adopted the following year at the 66th session of the Regional Committee for Europe in 2016. The implementation of the Strategy and Action Plan is periodically followed up by the WHO Regional Office for Europe. The results of the first follow-up survey are reported in Chapter 3.

The influx of refugees and migrants into the WHO European Region since 2015 has come in a series of repeated waves encompassing from tens to several hundreds of refugees and migrants, often simultaneously in different areas, and increasing significantly in frequency during the summer months. The speed and conditions with which these mobile populations arrived, and the number of people involved, created challenges for the countries receiving them. Refugees and migrants with pre-existing conditions or ones that they were unaware of (e.g. cardiovascular diseases, diabetes, pregnancy or malignancies) might not have had access to medical attention or treatment before or during their travel and arrive needing treatment. Apart from complications arising from lack of care, common infections acquired during displacement and migration and lack of nutrition can worsen these conditions. This necessitates identification of the problem and possibly intensive care on arrival. A commonly encountered problem relates to the integration of general medical services, psychosocial services and protection. Vulnerable or traumatized individuals (e.g. victims of trafficking and gender-based violence, victims of torture and trauma, and unaccompanied or orphaned minors) often have both physical and mental disorders. Uncertainty or insecurity related to the outcome of asylum claims, housing, family separation, employment prospects and future expectations all impact the health of new arrivals regardless of prior traumatization.

To gain further knowledge of the Member States health systems and their current integration of the Strategy and Action Plan, a survey was conducted in 2018. This first survey of Member States revealed progress in strategic planning and policy development to meet the health needs of refugees and migrants in the Region. A national focus on advocating for a rights-based and multisectoral approach to health was reported by more than half of the 40 responding Member States and was only slightly exceeded by attention to the issue of communicable diseases. There is a lack of reliable, comparable and nationally representative data on refugee and migrant health and one reason for this is that refugee and migrant health-related variables are not commonly included in national datasets: only 20 of the 40 Member States responding to the survey included these variables in their national datasets.

The development of a comprehensive refugee and migrant health agenda needs to encompass aspects for both the long-term, structural and widespread presence of refugees and migrants within communities (whether regular or irregular) and the acute sudden arrivals of mixed flows. The development or adaptation of policies and plans should preferably build on national population-based health strategies and be coherent with country-specific refugee and migrant profiles. At both the national and the local decentralized levels of the health system, it is important to enhance stewardship for implementation of the Strategy and Action Plan. This entails identifying and mandating designated officials, services or departments to lead and ensure accountability and consolidation of achievements during the scaling-up phase of the Strategy and Action Plan. Lack of a defined health sector stewardship can lead to fragmentation and poor accountability.

Refugees and migrants are entitled to the same universal human rights and fundamental freedoms as all people, which must always be respected, protected and fulfilled. However, refugees and migrants are distinct groups governed by separate legal frameworks. Only refugees are entitled to specific international protections defined by international refugee law. The term migrant is all embracing and lends itself to varied interpretations. The fact is that various categories of migrant might have very diverse health needs and outcomes, depending on a plethora of individual and process-related factors. There are two aspects related to policies to consider in refugee and migrant health. The first concerns the explicit adoption or application of policies that specifically ensure equity and coverage for various migrant groups. Associated with this mainstream strategy is the inclusion of an explicit reference to refugees and migrants within general population-based or disease-specific health policies. The second aspect is to ensure that policies in other sectors do not cause adverse health outcomes for refugees and migrants. This complex endeavour is better achieved when the health sector ensures stewardship, promotes the observance of fundamental health principles and engages in constructive multisector dialogues, not only domestically but also regionally and globally. Global policy instruments and multilateral agreements can at times be important in driving a more stringent domestic policy coherence. A major challenge is represented today by xenophobia, often explicit racism, and sovereignty issues that risk setting back currently achieved progress. Delivering high-quality health care to those who need it most is one of the basic components of global health. To complete that task, accurate and relevant health information is required to support evidence-informed policy planning and development. At the same time, the complexity and diversity of modern displacement and migration will demand that any empirical approach to address refugee and migrant health issues in future is founded on accurate and reliable information.

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